Estimating Area-Based Influences on Urban-Rural Inequalities in Health Outcomes: A Longitudinal Multilevel Epidemiological Investigation

Abstract

The process of urbanization can be described as one of the major global environmental changes directly affecting human health. Yet, the investigation of global rural-urban environments across regions and across continents has not been adequately considered in health studies, despite the comingled global, regional, national and sub-national influences on urban and rural differences in health over time and space. This study contributes to fill this gap by using aggregate data on 217 national populations from 86 countries over a historical period from 1985 to 2009. These 86 countries from Africa, Asia, Latin America and Europe capture various contexts of demographic, epidemiological and health landscapes over the past 25 years. Within a multilevel framework, these country-level longitudinally constructed data are nested within regions within continents around the world. Our research questions concern the changes over time (between 1985 and 2009) and space (across countries nested within four continents and 13 regions within the latter) in covariates of infant mortality in urban environments compared with rural environments, while addressing issues of variability in exposure and outcome variables. While studies have consistently identified clustering of poor health and mortality in urban areas, relatively little research has examined how stable space–time clustering are over an extended period of time. Our study proposes the integration of spatial and temporal analysis to explicitly model the possible patterns and changes in space–time clustering as well as the extent of disparities in infant survival between urban and rural areas, in order to more fully inform the policy makers and researchers about their dynamics. We found that unmet need for family planning is a major determinant of urban disadvantage in child survival among urban populations, that infant mortality rates in national urban populations are closely linked to poverty, that exclusive breastfeeding is a strong protective factor in urban environments whereas it has no significant effects in rural populations, and that there are important and significant variations in urban populations across countries within regions or continents and across waves of surveys within countries. This chapter considers the subject of urban versus rural health inequalities within the discussions of urban poverty and rural-urban differences in health, and provides an enlightened understanding on such distinct inequalities.

This work was supported in part by a grant from the International Relations Office of the University of Montreal, Canada. Supplemental support was provided by the International Union for the Scientific Study of Population (IUSSP).